Sullivan told MedPage Today, "There are a number of people who self-injure as a means of coping with feelings of overwhelming distress. By preventing such individuals from injuring themselves, it is possible to increase such distress with the result that the desire to self-injure becomes overwhelming. This may result in more extreme attempts at self-injury."

He noted that efforts to prevent self-harm are not entirely benign. "In hospital settings, this may involve quite intrusive practices such as the use of continuous observation to try and ensure the person's safety. I argue that paradoxically this may increase the risks."

Sullivan pointed out that harm minimization -- or interventions to decrease the immediate harm associated with self-injury -- can reduce the potentially deleterious effects of engaging in high-risk behaviors, when used as part of a broader clinical engagement.

Instead of forcibly stopping an individual from self-harm, he suggested alternatives for mitigating the behavior, such as the provision of sterile cutting implements; better education on how to self-injure more safely to avoid blood poisoning (sepsis) and infection; and therapy to help individuals understand and cope with their behavior.

He drew a parallel with drug addicts, for whom harm minimization is now accepted practice. In some situations, users are provided with clean needles and safe environments intended to reduce their short-term health risks while treatment of their underlying problems may be pursued.

Sullivan gave a fictitious example of a 35-year-old woman with long-term mental health issues who had engaged in cutting since her teen years. She described becoming anxious and distressed if prevented from cutting herself as a coping mechanism. In-patient "attempts at preventing self-injury have not always been successful and on occasions she has been so desperate to injure herself that she has made use of more dangerous methods of self-injury such as ligatures," Sullivan wrote.

Too Risky

In their editorial, Pickard and Pearce agreed that supporting autonomy and independence among vulnerable people is "fundamental to good clinical practice."

But they agreed with little else in Sullivan's proposal. "Of all the various measures that could, in principle, be adopted to help [patients with a history of self-injury], the forms of harm minimization that Sullivan advocates in inpatient settings do not strike us as the measures we ought to promote," they said.

"For self-injuring patients themselves -- let alone when we factor in the potential impact on other patients and staff -- the balance between costs and benefits of these forms of harm minimization for self-injury does not tip in their favor," they stated.

Pickard and Pearce noted that it's well-established that self-injury can be contagious, whether among patients in the hospital ward or among friend groups and social media channels, and suggested that Sullivan did not seriously consider how the harm minimization approach may affect an individual's low self-esteem, negative core beliefs, and emotions like shame and self-hatred.

"In other words, facilitated self-injury may give patients the message: 'We won't stop you from hurting yourself because you are not worth it,'" they wrote.

Other criticisms of harm minimization are that the practice sends mixed messages, fails to help people to kick their addictions, and is not always cost effective.

Sullivan acknowledged these criticisms. "I accept that in some cases [such as with individuals who are suicidal or whose self-injury is so dangerous it may become life threatening] more restrictive approaches are both necessary and proportionate," he wrote.

While there are certainly difficulties in implementing the practice -- mainly legal implications and professional struggles with the idea of supporting self-injury -- harm minimization may be clinically and morally justified in specific situations, he stated.

Sullivan, Pickard, and Pearce disclosed no relevant relationships with industry.

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